HospitalInspections.org

Based on observation and interview the facility failed to maintain a sanitary environment resulting in the potential for transmission of infectious disease amongst patients served. Finding include:

On 5/17/2017 at approximately 1100 during the initial tour of the facility it was noted that three hand washing sinks located in the dietary area were not equipped with wrist blade controls to enhance good hand washing techniques. This finding was reviewed and confirmed with the Director of Plant Operation.

Based on record review, interview and policy review, the facility failed to provide intervention, monitor and stabilization to 1 of 5 patients (patient #1) who presented to the emergency department with suicidal ideation, depression, or behavioral issues, resulting in the potential for self-harm. Findings include:

On 05/16/17 at approximately 1030 during record review of the document titled "Emergency Room General Medicine Complaint" dated 04/27/17 at 0320, for patient #1 it was determined that the patient was a 25 year old male who was brought into to the Emergency Department (ED), accompanied by the local police department (Public Safety), but not in their custody. It was noted that the patient had a past history of depression, alcoholism, self-mutilation, three suicide attempts and anxiety. "Public Safety states PT (patient) walked into the Public Safety Office, asking for help. PT said to nurse that "if I had a gun I would pull the trigger." It was also noted "He does have a plan to kill himself with a gun." According to the document titled "Laboratory" dated 04/27/17, Patient #1's Blood Alcohol was noted at 219, with the normal range of 0 mg-10 mg. Facility B (local behavioral health system), "will not even come into see the patient unless their Blood Alcohol level is 100 mg or less" per Staff A.) His drug screen was also noted as being positive for opiates.

Also noted on "04/27/17 at 0445: PT asking if he can leave, it was explained to PT the importance of being seen by Facility B, PT also informed him that if he left AMA (against medical advice), nurse will call public safety. PT verbalized understanding." 0450: "PT leaves ER exam room out into ER waiting room. Regional (911 operator) reached, informed that PT leaving AMA and of PT suicidal ideation. Description of PT given to Regional. Charge nurse and DR notified." 0452: "PT seen walking out of ER door and across parking lot towards highway." 0515: "Regional call back to inform that Public Safety on a complaint and are aware of PT leaving." 0548: "(Local) Public Safety called, aware PT had left AMA."

During review of the document titled "Emergency Room Note" dated 04/27/17 at 0726 under the heading "Assessment /Plan" the Emergency Room physician noted " ...Given that I feel that he is a substantial risk to himself and the public, (Local) Public Safety was again notified to hopefully take him into protective custody and when he is sober he may be returned for ongoing psychiatric evaluation and placement into an inpatient psychiatric facility." Also stated " ...Some of these withdrawal symptoms might be masked by his acute alcohol intoxication. Will require continued observation to make this determination. Likely to take 10-12 hours for his levels to return to normal to facilitate behavioral health evaluation."

On 05/16/17 at approximately 1500, during an interview with Staff A, he confirmed that the according to the facility's policy, the Emergency Department let an active suicidal, intoxicated patient leave their facility ("because they thought the police would be able to pick him up right away").

On 05/17/17 at approximately 1100 during review of the policy titled "Suicide Precautions" with a review date of "August 2011" it was determined under the heading "Implementation" "B. Precautions for patient safety and request for assessment will be implemented immediately upon any patient, patients family or visitors report of patients intent for self-harm. Precautions will be implemented when any hospital staff person has been witness to self-harm behaviors or statements regarding intent to self-harm. Screening/Ideation: Threatening to hurt or kill him/ herself, or talking of wanting to hurt or kill him/herself. Additional Warning Signs: Increased Substance (alcohol or drug) use. Safety Precautions: If the patient who is on general suicide precautions or under constant observation attempts to leave against medical advice (AMA), nursing staff should make efforts to convince patient not to leave and the physician should be contacted. In addition, nursing staff should request assistance from Community Mental Health, the patient's family and law enforcement as necessary and complete and Occurrence Report."

On 05/17/17 at approximately 1100 during review of the policy titled "Patients under the influence of alcohol" with a revision date of "July 24, 2012" it was determined under the heading "Procedure: #4. A nurse should stay with the patient in the emergency/exam room. Nursing Considerations: b. The patients safety should be protected by: ii. Never leaving the patient alone."